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Immunization Action Coalition
Ask the Experts
As appeared in the May 2012 issue of Needle Tips
Click here for PDF version
Immunization questions
Q:
Please review the new recommendations for the use of Tdap in people 65 years and older.
A:  
At its February 2012 meeting, the Advisory Committee on Immunization Practices (ACIP) voted to recommend Tdap for adults age 65 years and older. CDC posted the provisional recommendations on its website on March 21 at www.cdc.gov/vaccines/recs/provisional/downloads/Tdap-feb2012.pdf.
Two Tdap vaccines are currently licensed in the United States. They are Boostrix (GSK), approved for use in people age 10 years and older, and Adacel (sanofi pasteur) approved for use in people age 11 through 64 years.
The provisional recommendations state the following:
Give a single dose of Tdap to previously unvaccinated adults age 19 years and older.
 
Give the Tdap dose regardless of the interval since the person last received a tetanus or diphtheria toxoid-containing vaccine.
 
Give the Tdap dose to adults for whom it is recommended if no record of previous administration exists.
Do not miss an opportunity to give Tdap to people age 65 years and older. Administer the vaccine you have available—either Boostrix or Adacel. When feasible, give Boostrix to adults age 65 and older. However, either vaccine product provides protection and is considered valid for use in people in this age group.
 
Q:
Is there an upper age limit for Tdap administration? For example, should I vaccinate an 85-year-old?
A:  
There is no upper age limit for Tdap vaccination. A one-time dose of Tdap is recommended for all adults.
 
Q:
If HPV vaccine is given subcutaneously (SC) instead of intramuscularly (IM), does the dose need to be repeated?
A:  
Yes. No data exist on the efficacy or safety of HPV vaccine given by the subcutaneous route. All data on efficacy and duration of protection are based on a 3-dose series given on the approved schedule and administered by the intramuscular route. In the absence of data on subcutaneous administration, CDC and the manufacturers recommend that a dose of HPV vaccine given by any route other than intramuscular be repeated. There is no minimum interval between the invalid (subcutaneous) dose and the repeat dose.
Editor's note: The question above is identical to a question that appeared in "Ask the Experts" in the February 2012 issue of Needle Tips. The answer, however, is different. The answer given in February generated significant discussion, which led CDC experts to modify the answer.
 
Q:
Which children should receive PPSV vaccine (in addition to PCV13)? At what age should they receive it? What about older high-risk children who never received PCV13—should they get it now?
A:  
PPSV is recommended for children with an immunocompromising condition, or functional or anatomic asplenia, and also for immunocompetent children with chronic heart disease, chronic lung disease, diabetes mellitus, cerebrospinal fluid leak, or cochlear implant. Administer
1 dose of PPSV to children age 2 years and older; administer it at least 8 weeks after the child has received the final dose of PCV. Children with an immunocompromising condition, or functional or anatomic asplenia should receive a second dose of PPSV 5 years after the first PPSV. Older high-risk children who have not yet received a dose of PCV should receive it now. To view a table describing these recommendations in more detail, see IAC's provider-education piece titled "Recommendations for Pneumococcal Vaccine Use in Children," at www.immunize.org/catg.d/p2016.pdf.
 
Q:
Which adults need to receive PPSV prior to age 65 years?
A:  
PPSV is recommended for adults age 19 through 64 years who currently smoke cigarettes; reside in nursing homes or long-term care facilities; have chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); asymptomatic or symptomatic HIV (vaccinate as soon as possible after diagnosis). Public health authorities may consider recommending PPSV for American Indians/Alaska Natives who live in areas where the risk for invasive pneumococcal disease is increased. Please see IAC's 'Pneumococcal Polysaccharide Vaccine: CDC answers your questions” at www.immunize.org/catg.d/p2015.pdf.
Editor's note: The next Q&A explains which adults need a second dose of PPSV.
 
Q:
Which adults should receive a second dose of PPSV?
A:  
One-time revaccination 5 years after the first dose is recommended for people age 19 through 64 years who have functional or anatomic asplenia (including persons with sickle cell disease or splenectomy patients); chronic renal failure (including dialysis patients) or nephrotic syndrome; are immunocompromised, including those with HIV infection, leukemia, lymphoma, Hodgkin's disease, multiple myeloma, generalized malignancy; are receiving immunosuppressive therapy (including long-term systemic corticosteroids or radiation therapy); or who have received an organ or bone marrow transplant.
Adults who receive their first PPSV at or after age 65 years should receive only a single dose, regardless of their health status. Please see IAC's "Pneumococcal Polysaccharide Vaccine: CDC answers your questions" at www.immunize.org/catg.d/p2015.pdf.
 
Q:
PCV13 is now licensed for use in adults, but I don't see anything about it in the 2012 adult immunization schedule. How should it be used?
A:  
FDA licensed PCV13 (Prevnar13; Pfizer) for adults age 50 years and older in December 2011. At its February 2012 meeting, ACIP reviewed the evidence for the use of PCV13 in adults but did not vote on recommendations for its use in adults. As always, physicians can use their clinical judgment and use FDA-licensed vaccines if they would like to do so.
 
Q:
What are the minimum intervals for giving the 3-dose series of Twinrix (hepatitis A-hepatitis B vaccine; GSK)?
A:  
Minimum intervals for Twinrix are 4 weeks between dose #1 and dose #2, and 5 months between dose #2 and dose #3.
 
Q:
PCV13 is now licensed for use in adults, but I don't see anything about it in the 2012 adult immunization schedule. How should it be used?
A:  
FDA licensed PCV13 (Prevnar13; Pfizer) for adults age 50 years and older in December 2011. At its February 2012 meeting, ACIP reviewed the evidence for the use of PCV13 in adults but did not vote on recommendations for its use in adults. As always, physicians can use their clinical judgment and use FDA-licensed vaccines if they would like to do so.
 
Q:
What are the minimum intervals for Twinrix (hepatitis A-hepatitis B vaccine; GSK)?
A:  
Minimum intervals for Twinrix are 4 weeks between dose #1 and dose #2, and 5 months between dose #2 and dose #3.
 
Q:
When reconstituting a vaccine with the manufacturer-supplied diluent, should the clinic nurse administer exactly 0.5 mL and then discard the rest?
A:  
No. The nurse should administer the entire volume supplied. The package inserts include this information.
 
Q:
Should we fill out a report with the Vaccine Adverse Event Reporting System (VAERS) if a patient faints after getting a vaccination, even if no injury or complication resulted?
A:  
Yes. VAERS looks for trends, so such information is helpful. To find out about VAERS and the kinds of events you should report to the system, visit vaers.hhs.gov/index.
 
Q:
If a new version of a VIS becomes available, is it legal for us to use up the outdated VISs or do we have to discard them and provide the most up-to-date version?
A:  
When a new or updated VIS is released, CDC posts information on its website that indicates if healthcare providers can use up their stock of the old version of the VIS or should discard the old version and begin using the new VIS right away. The answer generally depends on how significantly the VIS was changed. You can tell what has been changed recently by going to the CDC website at www.cdc.gov/vaccines/pubs/vis/vis-news.htm.
To determine whether you need to use the new one versus the old, you can have CDC email you an update by subscribing to CDC's free email subscription service at www.cdc.gov/emailupdates. After you've signed up, you'll be taken to a page with lots of options. Once there, check the Vaccine Information Statements box under the section titled "Vaccines & Immunizations."
 
Q:
A 10-year-old girl came to our immunization clinic, and the nurse noted crusted lesions on her arms and legs. The parent said the child had had chickenpox a week earlier. The girl was not ill, so we vaccinated her. But now I am wondering if her recent case of chickenpox might interfere with her immune response to vaccines.
A:  
Do not be concerned that the girl's recent case of chickenpox will interfere with her immune response. Previous history of chickenpox disease, even recent disease, will not interfere with the immune response to different vaccines. To review the true contraindications and precautions to vaccination, consult IAC's "Guide to Contraindications and Precautions to Commonly Used Vaccines" at www.immunize.org/catg.d/p3072a.pdf. Another helpful resource is ACIP's General Recommendations on Immunization. It contains a useful table titled "Conditions commonly misperceived as contraindications to vaccination." The table is available at www.cdc.gov/vaccines/recs/vac-admin/contraindications-misconceptions.htm.
 
Q:
A child wiggled when we were injecting a dose of vaccine, and approximately half the dose was lost. Should we revaccinate the child? If so, when?
A:  
When injectable vaccine volume is lost (patient moves, syringe leaks), it may be difficult to judge how much vaccine the patient actually received. In general, you should treat this as a nonstandard injectable dose and should not count it. If it was an inactivated vaccine, you should re-immunize the person as soon as possible. If it was a live vaccine, you can give another dose if you detect the error on the same clinic day; otherwise you should wait 28 days to give the next dose. However, if part of a dose of an oral vaccine (rotavirus) was spit out, count the dose and do not administer a second dose.
 
Q:
Should a healthcare worker who has just received a dose of a live virus vaccine (varicella, MMR, LAIV, yellow fever) stay away from work for a certain number of days?
A:  
No. Healthcare workers should not refrain from working after receiving live virus vaccines or any other vaccine.
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Immunization Action Coalition  •  Saint Paul, MN
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 5U38IP000290) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.